Rosen & Barkin's 5-Minute Emergency Medicine Consult (90 page)

• Patients with parasitemia >4%, severe anemia (hemoglobin <10 g/dL), significant symptoms or complications, or need for exchange transfusion require admission:
  
  • Respiratory distress
    
  • Hypotension or shock
    
  • New renal insufficiency or hepatic failure
    
  • Altered mental status
    
  • Severe hemolysis (jaundice, hematuria)
    
• Admission should also be considered in patients without any of the above, but who have risk factors for developing severe disease (see above):
  
  • Elevated alkaline phosphatase, elevated WBC counts, and male gender were predictive of more severe outcomes
    

• Patients with asymptomatic, mild, or moderate disease
  
• Parasitemia <4%
  
• Intact spleen, immune competent
  
• Able to tolerate oral medications
  

Immunodeficient patients are more likely to have persistent or relapsing disease following initial treatment and should be referred for infectious disease consultation.

Patients diagnosed with babesiosis should follow up with their primary care physician or infectious disease specialist for monitoring of parasitemia levels following completion of antibiotic course in symptomatic patients and at 3 mo in asymptomatic patients.

• Babesiosis can be a life-threatening disease in asplenic patients.
  
• Consider babesiosis as a potential cause of respiratory distress/shock in patients with a travel history to an endemic area.
  
• Microscopy findings may not be present in early stages of disease when parasitemia levels are low.
  

• Gelfand JA, Vannier EG. Clinical manifestations, diagnosis, treatment, and prevention of babesiosis.
  UpToDate
  . 2012.
  
• Leder K, Weller PF. Epidemiology and pathogenesis of babesiosis.
  UpToDate
  . 2012.
  
• Vannier E, Gewurz BE, Krause PJ. Human babesiosis.
  Infect Dis Clin North Am
  . 2008;22(3):469–488, viii–ix.
  
• Vannier E, Krause PJ. Human babesiosis.
  N Engl J Med
  . 2012;366:2397–2407.
  

See Also (Topic, Algorithm, Electronic Media Element)

Lyme Disease

CODES

088.82 Babesiosis

BASICS

• Low back pain (LBP):
  
  • Refers to pain in the area between the lower rib cage and the gluteal folds, often with radiation into the thighs
    
• Sciatica:
  
  • Pain in the distribution of the lower lumbar spinal roots
    
  • May be accompanied by neurosensory and motor deficits
    
• Pain classification:
  
  • Acute: <6 wk
    
  • Subacute: 6–12 wk
    
  • Chronic: >12 wk
    

• Nonspecific musculoligamentous source (great majority) (e.g., muscle, ligament, fascia)
  
• Herniation of the nucleus pulposus
  
• Degenerative joints or discs
  
• Spinal stenosis
  
• Anatomic abnormalities—especially spondylolisthesis
  
• Fractures from trauma and osteoporosis
  
• Underlying systemic diseases (minority):
  
  • Neoplasm
    
  • Infections
    
  • Vascular (dissection, aneurysm, and thrombosis)
    
  • Renal
    
  • GI
    
  • Pelvic organ pathology
    

DIAGNOSIS

• Musculoligamentous:
  
  • Poorly localized and dull back/gluteal pain without radiation past the knee.
    
  • Usually no objective neurologic signs.
    
  • Back spasm is a variable and poorly reproducible finding.
    
• Sciatica:
  
  • Sharp, shooting, well-localized pain
    
  • Leg complaints often greater than back
    
  • May present with
    
    • asymmetric deep tendon reflexes
      
    • decreased sensation in a dermatomal distribution
      
    • objective weakness
      
• Massive central disc herniation (cauda equina):
  
  • Decreased perineal sensation
    
  • Urinary retention with overflow incontinence
    
  • Fecal incontinence
    
• Infectious processes:
  
  • Fever
    
  • Localized percussion tenderness of the vertebral bodies
    
• Bony lesion:
  
  • Continuous pain that does not change with rest
    
  • Constitutional symptoms
    
• Vascular etiology:
  
  • Severe, often “ripping or tearing” pain
    
  • May be associated with cold or insensate extremities
    

• Can assist with focusing and narrowing differential diagnosis. Helps rule out concerning pathology for pain:
  
  • Intensity
    
  • Quality
    
  • Location and radiation
    
  • Onset
    
  • Exacerbating or remitting factors
    
  • Social or psychological factors
    
  • Response to previous therapy
    
• Risk factors for serious disease:
  
  • Fever
    
  • Constitutional symptoms
    
  • Trauma
    
  • Age >60 yr
    
  • History of cancer:
    
    • Especially those that metastasize to bone
      
  • Chronic steroid use
    
  • IV drug use
    
  • Recent instrumentation or bacteremia
    
  • Night pain
    

• Fever
  
• Spasm or soft tissue tenderness is a poorly reproducible finding:
  
  • Vertebral tenderness sensitive but nonspecific for infection
    
• Straight leg raise—elevating the leg while supine reproduces sciatic symptoms:
  
  • Ipsilateral raise highly sensitive but not specific
    
  • Crossed leg raise highly nonspecific but insensitive
    
• Ankle and great toe dorsiflexion and ankle plantar flexion (L5, S1 nerve roots)
  
• Ankle deep tendon reflexes (S1)
  
• Dermatomal sensory exam:
  
  • Assess for saddle anesthesia
    
• Rectal sphincter tone
  

• Thorough history and physical exam, including detailed neurologic and vascular exam
  
• No specific tests are needed for uncomplicated musculoligamentous or sciatic pain
  
• Rapid diagnostic testing and vascular consultation concerning aortic etiology
  

• Urinalysis for suspected:
  
  • UTI/pyelonephritis
    
  • Prostatitis
    
• ESR:
  
  • Highly sensitive, though nonspecific for infectious or inflammatory etiologies
    
  • Used for screening to help rule out disease
    

• Lumbosacral radiograph:
  
  • Significant trauma
    
  • Age >50–60 yr
    
  • History or signs/symptoms of cancer
    
  • Fever
    
  • IV drug user
    
  • Pain at rest
    
  • Suspicion of inflammatory etiology
    
  • Pain that does not improve after 4 wk
    
• Bedside US:
  
  • Full bladder suggests urinary retention
    
  • Abdominal aortic aneurysm (AAA)
    
  • Abdominal CT if patient stable
    
• MRI:
  
  • Suspicion of abscess:
    
    • Fever, immunocompromised, IVDA, history of bacteremia
      
  • Suspicion of metastatic tumor:
    
    • Systemic cancer, weight loss
      
  • Suspicion of hematoma:
    
    • Anticoagulation, recent spinal anesthesia
      
  • Rapidly progressing neurologic symptoms
    
  • Urinary retention or fecal incontinence associated with back pain
    
• CT:
  
  • Secondary modality for diagnosis of abscess, cancer, or massive disc when MRI unavailable
    
  • Test of choice in imaging potential unstable fractures
    
  • Excellent sensitivity to evaluate vascular etiology in stable patient
    

• Spinal origins—in the majority of patients no precise anatomic site is discovered:
  
  • Musculoligamentous (majority)
    
  • Discogenic
    
  • Fracture
    
  • Spondylolisthesis
    
  • Ankylosing spondylitis
    
  • Osteomyelitis
    
  • Epidural abscess/hematoma
    
  • Neoplasm
    
• Nonspinal causes:
  
  • AAA
    
  • Prostatitis
    
  • Upper UTI
    
  • Abdominal neoplasm
    
  • Renal colic
    
  • Aortic dissection